Download document 8032473

Sample Operations Manual
2010
version SAMPLE – Operations Manual 2010 Sample Operations Manual
2010
Table of Contents
Clinic Information
Mission Statement
Vision Statement
Clinic History
Core Values
Goals & Action Plans
Clinic Director
Job Description & Responsibilities
Organizational Chart
Office Manager
Job Description & Responsibilities
Transport Personnel
Job Description & Responsibilities
Transport System Contract
Training Checklist
Veterinarian
Job Description & Responsibilities
Surgery Instructions
Medical Support Staff
Job Description & Responsibilities – Veterinary Technician
Job Description & Responsibilities – Veterinary Assistant
Medical Support Staff Job Requirements
Training Protocol
Standard Operating Procedures
Office Procedures
Surgical Program Requirements
Surgery Room Procedure
AM / PM Procedures
Surgical Pack Procedures
Disease Control Procedures
Budget Process & Financial Guidelines
Important Phone Number, Websites, & Resources
Risk Management
3
4
4
4
4
4
5
6
7
8
9
10
11
12
14
15
16
17
27
28
29
29
31
39
40
41
45
46
47
51
55
56
Insurance Guidelines
Crisis Response Procedures
Code of Conduct
57
58
59
60
Forms
61
Sample Operations Manual
Clinic Information
Clinic Information
3
Sample Operations Manual
Clinic Information
Mission Statement
Insert Mission Statement Here
Vision Statement
Insert Vision Statement Here
Clinic History
Insert Clinic History Here
Core Values
Insert Core Value Here
Goals & Action Plans
Insert Goals & Action Plans (for the current year)
4
Sample Operations Manual
Clinic Director
Clinic Director
5
Sample Operations Manual
Clinic Director
Job Description & Responsibilities
JOB TITLE:
Clinic Director
JOB SUMMARY:
To give direction and leadership toward the organization’s mission,
strategy, and annual goals and objectives. To implement and manage
the strategic programs, services, goals and objectives of the organization.
REPORTS TO:
Board of Directors
RESPONSIBILITIES:
1. Support operations and administration of Board by advising and informing Board members.
Operate organization according to policies set by Board of Directors. Report progress and
statistical performance measures quarterly.
2. Manage the design, marketing, promotion, delivery, and quality of programs and services.
Identify and implement the goals, objectives, methods, and resources necessary to
accomplish the specific mission and programs of the organization (strategic direction
planning, business planning, project planning, staff planning, etc.
3. Recommend yearly budget for Board approval and manage organization’s resources within
those budget guidelines.
4. Oversee the human resources of the organization according to personnel policies and
procedures.
5. Write and oversee grant applications including planning and implementation, identify
resource requirements, research funding sources, establish strategies to approach grants,
approve proposals and administrate records, documentation, and appropriate
expenditures.
6. Measure the organization’s performance with regard to finances and specific program
services.
6
Sample Operations Manual
Clinic Director
Organizational Chart
Here are 2 examples of an organizational chart (adjust accordingly)
SAMPLE 1
Board of
Directors
Clinic
Director
Veterinarian
Office
Manager
Vet Tech
Volunteer
Transport
Personnel
Vet Assist
Sample 2
Board of
Directors
Clinic
Director
Veterinarian
Vet Tech
Office
Manager
Vet Assist
Volunteer
Transport
Personnel
7
Sample Operations Manual
Clinic Manager
Office Manager
8
Sample Operations Manual
Clinic Manager
Job Description & Responsibilities
JOB TITLE:
Office Manager
JOB RELATIONSHIPS:
Reports to Executive Director/Director of Clinic Operations; provides
supervision for all office personnel and volunteers.
JOB SUMMARY:
Responsible for overall operations of office and service counter; maintain
complete records of clinic activities.
RESPONSIBILITIES:
Supervision and Client Services:
1. Oversee operations of the main service counter.
2. Ensure quality client service.
3. Report employee or client problems to Director.
4. Assist the Executive Director in administrative duties.
5. Make daily bank deposits.
6. Maintain accounts receivable.
Patient Information:
1. Maintain patient database.
2. Create rabies certificates.
3. Ensure proper paperwork goes home with each patient.
4. Maintain complete records for all patients.
5. Ensure that proper supplies are kept on hand.
6. Provide in-person and telephone client services and answer questions.
7. Ensure that owners are happy and comfortable with leaving their pets in a safe and loving
environment.
Office Manager Duties:
1. Billing:
• Check with veterinary technician to see if all scheduled vaccines were administered and all
scheduled surgeries were performed. If not, remove appropriate charges from invoice; add
anything extra the animal may have received.
• Post invoices at the end of every day.
• Check daily invoices for errors.
• Retain a copy of each invoice.
2. Accounts Receivable:
• When payments are received, make a copy of all checks and attach to appropriate
retained invoices.
• Record payments on the day sheet.
• Enter payments in the database.
3. Account Reconciliation:
• Prepare monthly accounts receivable reports.
• Contact any overdue accounts.
• Send report to the accountant.
• If a problem cannot be resolved, notify the Director.
9
Sample Operations Manual
Transport Personnel
Transport Personnel
10
Sample Operations Manual
Transport Personnel
Job Description & Responsibilities
JOB TITLE:
Transport Personnel
JOB RELATIONSHIPS:
Reports to Executive Director
JOB SUMMARY:
Responsible for transport of animals between shelters and the clinic,
including scheduling of transportation and maintenance of vehicle.
RESPONSIBILITIES:
General transporting:
1. Schedule pick-up and delivery by the month; accommodate groups with regard to day and
time, if possible.
2. Be punctual for pick-ups; if unavoidably late, advise by phone.
3. Carefully screen all animals to determine fitness for surgery. Any animals showing signs of
illness will not be loaded on transport.
4. Be careful and gentle with animals in loading and unloading.
5. Make sure all animals are in crates and crates are closed.
6. Secure all crates in back of transport vehicle.
7. Call the clinic with an animal count at completion of pick-up.
8. Make sure all animals are on return delivery (check-off on transport list).
9. Drive defensively with care and caution; observe speed limits and all good driving rules.
Vehicle Care:
• Clean and sanitize the animal compartment of vehicle each day.
•
Clean the exterior and driver compartment of vehicle on a regular basis.
•
Responsible for maintenance of the vehicle on a regular basis; breakdowns jeopardize the
animals and cause unnecessary delays.
11
Sample Operations Manual
Transport Personnel
Transport System Contract
OUR GOAL
The goal of [CLINIC NAME] is to reduce future generations of unwanted animals through the
non-lethal solution of surgical sterilization. In addition, by requiring rabies vaccinations at the
time of surgery, we hope to help control the incidence of rabies in our community.
PAPERWORK
Admission forms will need to be obtained from [CLINIC NAME] at a cost of $0.00 per xxx. All
forms must be completed. If there is not an owner signature, we cannot legally do the surgery.
Please be certain that every animal has an admission sheet. If the owner has two or more
animals, an individual admission sheet is required for each animal.
WHAT OWNERS NEED TO KNOW
Surgical fees
Your organization will be invoiced for all patients received at the clinic. The invoice will be sent
in hard copy with your return transport.
Vaccinations.
The following vaccinations are available:
DA2LPPv
Bordetella
FVRCP
FELV
Rabies
(canine distemper/parvo)
(kennel cough)
(feline distemper combo)
(feline leukemia)
([CLINIC NAME] requires proof of rabies. If no proof is provided, the animal will
receive the vaccination and the owner will be charged.)
Pre-op instructions.
Animals older than 4 months must not have any food after 12:00 midnight the night before
surgery (water is okay). Animals younger than 4 mo. may have food and water. This is very
important for the safety of the animal. If there is any question that the animal may have had
food, please ask the owner to re-schedule.
Tattoos
All owners need to be notified that their animals will receive a small tattoo on their underbelly
near the incision sight. The tattoo is very important to identify that the animal has been spayed
or neutered. This is to ensure that if lost, the animal will not have to go through unnecessary
surgery in the future.
Prior medical concerns
Please ask the client if their animal has any prior medical concerns. Females that are pregnant
or in heat are done by [CLINIC NAME] daily; however, it is good to let the owner know that they
are at a slightly higher risk during surgery. Advanced age is also a concern; we require a preanesthetic blood panel before surgery for any animal eight years old and up.
Strays
Please let us know if female animals are strays and could already have been spayed.
Scheduling
Proper scheduling is crucial to the daily success of our clinic. It is very important to call in your
appointments (divided by sex and species) no later than 12:00 pm, three business days prior to
your transport. This gives us time to fill in any gaps with our public appointments. If we are not
12
Sample Operations Manual
Transport Personnel
notified of your appointments within 72 hours your transport may be canceled.
Name collars (disposable)
Make sure the animal’s name, the owner’s last name, and the shelter ID are on the animal’s
collar. If there is no owner a shelter number is required.
Animal carriers
It will be your responsibility to have enough carriers for your transport. Please make sure that all
carriers are lined with newspaper and labeled with the animal’s name and/or number.
Fees
Money and change are the responsibility of the organization; the driver does not carry change.
The shelter will be invoiced for all animals (shelter and owned) on their transport.
Dates and times
The transport schedule will be set up at least two weeks in advance. Normally you will have a
rotating schedule. However, the schedule is subject to change. Make sure to have the owners
arrive in enough time to do the paperwork, collar the animal, and label the carrier before the
transport van arrives.
Surgical Costs
Female dogs
Male dogs
Male cats
Female Cats
Vaccinations
Heartworm Test
FIV/Felv Test
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Signatures:
I understand and agree to follow the above procedures while participating in animal transport
with the [CLINIC NAME].
____________________________________________(Name)
____________________________________________(Organization)
Date:_________________________
_____________________________________________
[NAME], Clinic Director, [CLINIC NAME]
Date:_________________________
13
Sample Operations Manual
Transport Personnel
Training Checklist
TRANSPORT GROUP___________________
DATE OF TRANSPORT____________
PICK-UP SITE__________________________
PICK-UP TIME____________________
RETURN DATE________________________
RETURN TIME___________________
CHECKLIST
1. All scheduled animals and their corresponding paperwork should be ready at least 30
minutes prior to the arrival of the [CLINIC NAME] transport vehicle.
2. All pets must be secured in clean, plastic, size appropriate crates. For the health and safety
of the animals, wire crates are not acceptable. Doors on crates must fasten securely.
3. Make sure that bolts are not missing from the perimeter of the crate. If they are, please
fasten top and bottom of crate together with heavy-duty zip ties.
4. Animals should not be muzzled, for their own health and safety.
5. If pet owners send blankets, towels, toys, collars, leashes or other personal items in crates,
please inform them that there is no guarantee that these objects will be returned with their
animal.
6. No more than one animal allowed per crate! Exceptions are small puppies less than 16
weeks old (no more than 3 per crate) and domestic cats from the same house-hold (no
more than 2 per crate).
7. Feral cats must be in live traps.
8. EACH CRATE MUST BE CLEARLY MARKED WITH THE FOLLOWING IDENTIFYING INFORMATION:
Animal first and last name and the transport group’s ID letters or name.
9. All animals must have paper neckband/collars for identification. No regular collars, flea
collars or leads. Using permanent marker, please include the following information on the
neckband: animal’s first and last name and the transport group’s ID letters or name. For
very large dogs, or for fractious dogs or cats, the ID neckband may be attached to the crate
handle. PLEASE ENSURE ALL PAPERWORK HAS BEEN PROPERLY COMPLETED AND SIGNED BY
THE PET OWNER PRIOR TO THE ARRIVAL OF THE [CLINIC NAME] TRANSPORT VEHICLE.
10. A transport group representative must witness proof of rabies vaccinations and verification of
such must be initialed on the Admission Form. PLEASE NOTE: If there are no initials, [CLINIC
NAME] must administer a 1-year rabies vaccination and charge the transport group
accordingly.
11. Admission Sheet must be signed. [CLINIC NAME] will not perform surgery without a signed
admission form.
12. Please have sufficient number of staff/volunteers to help with the transport loading process.
14
Sample Operations Manual
Veterinarian
Veterinarian
15
Sample Operations Manual
Veterinarian
Job Description & Responsibilities
JOB TITLE:
Veterinarian
JOB RELATIONSHIPS:
Reports to Medical Director/ Executive Director, provides supervision for
all veterinary technicians, veterinary assistants, kennel staff and
volunteers.
JOB SUMMARY:
Responsible for daily care and sterilization of all surgical patients and
maintenance of preventative health programs and medical protocol.
Quality patient care is first and foremost.
RESPONSIBILITIES:
1. Supervise veterinary technicians, veterinary assistants and kennel personnel.
2. Examine animals pre-op to determine their ability to withstand surgery.
3. Perform surgical sterilizations.
4. Examine animals post-op as necessary to ensure appropriate healing.
5. Inoculate animals and provide recommendations for follow up care.
6. Supervise cleaning program for prevention of infectious/zoonotic disease.
7. Continue research and maintenance of safe and efficacious medical protocol regarding
anesthesia and surgery.
8. Supervise handling and recording of controlled substances by veterinary technicians.
9. Supervise post-op rechecks and order of medical treatments as necessary to ensure
complete surgical recovery.
10. Actively promote spay and neuter, and educate clients on responsible animal ownership.
11. Actively support associate staff and volunteers, and promote the development of skills
related to the advancement of our goals and mission.
12. Represent the [CLINIC NAME] in a professional and courteous manner at all times.
13. Provide quality service to clients, volunteers, and staff recognizing their individual
contributions to the success of our organization.
14. Participate on committees and special projects as assigned.
15. Other duties as assigned.
16
Sample Operations Manual
Veterinarian
Surgical Program Requirements
All patients are given a physical exam before any injections are given:
1.
2.
3.
4.
5.
6.
7.
Auscult heart and lungs
Mentation/activity level
Body condition (Tuft’s animal care and condition scale)
Ocular and/or nasal discharge
Hydration status
Mucous membrane color
Any obvious abnormalities
If any abnormalities are noted, a complete physical exam is performed including temperature
evaluation and a decision is made as to the animal’s fitness for surgery. The following conditions
are examples of basis for rejection:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
URI of any magnitude
Diarrhea
Vomiting
Moderate to severe skin disease
Ocular disease
Severe obesity
Poor body condition
Depressed attitude
Sneezing/coughing
Heart murmur
Anything that might indicate an undiagnosed condition that may compromise the patient
during anesthesia, recovery, and/or healing will be considered reason for refusing surgery.
Although the mission of [CLINIC NAME] is to sterilize as many animals as possible, OHEs and
castrations are still elective procedures, and the individual animal’s well-being comes first. If it is
in the animal’s best interest to have the surgery postponed, then arrangements are made to do
so.
Females that are in labor when they arrive are not subjected to surgery; at this point it is too late.
They are either sent home or given food, water, and a warm bed in a quiet environment and
allowed to give birth. Also, when a patient vomits undigested food, we will not do surgery on
that day. We may hold the animal over until the next day or reschedule, depending on the
circumstances.
Minor conditions that are noticed after induction are reported to the owners on the post
operative sheet, to be referred to an area veterinarian for treatment, and recorded on the
medical record. Cats have their ears checked by the staff during prep, and those that appear
to have ear mites may be treated. We have Doramectin for treating shelter, rescue, and feral
cats for ear mites. Most of these cats will never be seen by a veterinarian again, and we feel an
obligation to try to relieve them of such conditions while the opportunity exists.
Anesthesia is always to be avoided when not necessary.
All females over 16 weeks of age with unknown history must be shaved for signs of having
already been spayed (ABS). This includes shelter, rescue, and public animals that were stray.
Signs that indicate an ABS are: mid-line scar, tattoo, undeveloped nipples and vulva on an older
17
Sample Operations Manual
Veterinarian
female. Keep in mind that very large scars may indicate a C- section, which may have left the
uterus intact. The whole picture must be considered in each case. All males must be checked
for two testicles. Cryptorchid animals less than 6 months of age should be rescheduled to allow
time for the testicle(s) to descend. Male cats without testicles should be checked for cheek
development and spines on the penis to determine if they have already been neutered (ABN).
Prior to performing a cryptchorid surgery, the surgeon should palpate the inguinal area.
Final pre-op considerations
Doctors need to check their patient’s anesthetic machine for correct set-up before beginning
each and every surgery. Mistakes are sometimes made and early detection saves lives. Doctors
also need to check feline patients’ sex before draping in - occasionally a male is prepped as a
female, and it is ultimately the doctor’s responsibility to prevent a male cat from having his
abdomen opened. Also, always check female patients for scars - although we try to identify
ABS’s prior to pre-med, they are occasionally missed by the staff, and the doctor should not
make the mistake of missing a scar before opening the abdomen on an animal that has already
been spayed.
Surgery
Five knots on all sutures. This technique has been proven to eliminate dehiscence, and must
always be used.
Large bites on the Linea alba: include at least 5 to 8 mm muscle tissue in the linea closure in cats
and up to 10 to 12 mm in large dogs. We never use simple continuous patterns in the linea-only
cruciate or simple interrupted.
Large bites in the subcutaneous tissue. At least 3-layer closure-linea, SQ, and subcuticular plus
skin glue or staple/skin sutures.
No crushing sutures in closing - linea and subcutaneous tissue should be snugly and completely
closed but never crushed. Dead space should be closed and the SQ should be anchored at
least at both ends of the linea incision. Linea and subcutaneous tissue are closed with
absorbable suture.
Skin edges should be properly apposed - never allow one side to flap over the other or extend
above the other. Skin glue should not be applied between the skin edges but on the surface
after apposing the edges.
Miller’s knot - we use this knot on the ovarian pedicle and the uterine body. It is extremely
secure, minimizing complications. We may use a Miller’s knot in conjunction with a modified
transfixing ligature on the uterine body of a pregnant female with very large uterine vessels.
Modified transfixation ligature - We use this ligature on adult dog castrations. Canine castrations
are usually done as closed, except on older dogs where it is more difficult to separate the
epididymal ligament from the scrotum. If an open castration is performed, the vaginal tunic is
closed before placing the subcutaneous sutures.
Cat and puppy neuters, special technique: for neuters of cats and puppies under 12-14 weeks
of age, we tie the vas deferens and vessels off on themselves in a figure 8 knot. This knot is much
less likely to come untied than a simple square knot. A diagram is available illustrating this
technique.
18
Sample Operations Manual
Veterinarian
In cryptorchid male dogs, we have found that a para median incision through the muscle layers
is preferable to a midline incision since it allows easier location and externalization of
abdominally retained testicles.
Surgery begins as early as possible in the shift, and doctors should be ready to perform surgery at
this time.
One doctor should arrive earlier in order to examine animals to be approved for surgery as they
are checked in. Doctors rotate recovery. This is an informal arrangement made each week.
Post-operative care
To calm patients recovering from surgery, environmental stress is reduced as much as possible.
Human activity is minimized and lights are kept off. The door to the cat room is kept closed.
Doors to the dog kennel should be kept closed at all times. Blankets should be hung over cages
of overly excited patients.
Pain Management
Veterinary medicine now requires a standard of care that incorporates pain relief for patients
undergoing painful procedures. OHE and castration are both known to be painful procedures
requiring treatment for pain. Pain is best controlled by prevention, and incorporating effective
drugs into the pre-medication or induction protocol can effectively prevent windup of
nociceptors and greatly reduce the level of pain experienced by the patient, as well as the
amount of drug needed during recovery. Our protocol reflects this data. The current
recommendations encourage the use of multimodal analgesic therapy. In fact, two to three
different forms of analgesics used in combination appear to be the most effective. Of those
combinations, the most common ones utilized by boarded specialists are opioids with NSAIDS.
The recommendation that hydration status should be closely evaluated and that SQ fluids be
administered preemptively is appropriate. Specifically, in addition to Morphine for canine
patients and Buprenorphine for feline patients, supplemental pain medication is also utilized
(Meloxicam or additional Buprenorphine). Anecdotally, we have had serious post-operative
hemorrhaging resulting from the use of Ketoprofen in dogs, and no longer use this drug.
Supplemental Support
All pregnant females in the third trimester have an IV catheter placed and fluid therapy
administered appropriately during the procedure. Ideally, fluids should be warmed. Any other
patients needing fluid therapy for any other reason also receive it in SQ or IV form. Immediately
after removal of the uterus, fetuses of third trimester pregnancies are removed from the uterus
and euthanized.
All cats, kittens, puppies, and small dogs get hot water bottles or rice bags, and “sugar lips”
upon removal from the surgery table. Anyone showing signs of hypothermia gets a heated rice
bag and extra blankets as needed.
Every patient gets a clean, appropriately sized blanket; the patient’s entire body should be
placed on his/her own blanket, not on the larger community blanket, which covers the entire
recovery area. The recovery area needs to be kept clean at all times.
Adult male dogs may receive a scrotal wrap to help reduce the incidence of scrotal swelling
post-op. The scrotal wrap is removed prior to discharge.
Antibiotics are available for patients that need them (pyometras, URIs that aren’t caught until
after induction, sterile field contamination, etc.).
19
Sample Operations Manual
Veterinarian
Recoveries
Dogs stay in the recovery area until sternal or actively trying to get up. Cats stay until lifting their
heads. We have found that one of the best indicators of a normal recovery is level of
consciousness. Regardless of vital signs, an animal that is not regaining consciousness at a
normal rate should be closely assessed for post-operative hemorrhaging. If unresponsive to
stimulation, an abdominocentesis and hematocrit should be performed. The animal should be
re-anesthetized and explored if blood is obtained on the abdominocentesis and/or the
hematocrit level is of concern to the veterinarian. Patients are never left unattended until
consciousness has been regained - those that need to be monitored overnight for any reason
should be sent to a full service 24-hour facility for additional care, after the owners have been
contacted.
At the end of the day, all patients are given a final check by a doctor. They are assessed for
recovery status, signs of complications, and are ensured of a clean, dry, warm bed. Male cats
are especially prone to urinate on their beds during recovery. No patient should ever be made
to lie in a soiled bed overnight.
Cats having a rough recovery from Telazol may receive a low dose of sedative to smooth out
their recovery and prevent self-injury. The staff gives a small amount of dry food to recovered
adult patients at the end of the day. Pediatrics who are fully awake are given a small amount of
dry food and water. The water is always removed at the end of the day, not left in the kennel
overnight.
Re-checks:
When possible, doctors should try to see their patient’s re-checks and contact the owners of
their patients. This is not always possible with part-time doctors, so we try to assist when needed.
Health Exam for Dogs and Cats
• Eyes - Look for signs of discharge from the eyes. This is an indication of an upper
respiratory infection.
•
Nose - Look for signs of nasal discharge. This is also an indication of an upper respiratory
infection.
•
Body Condition - The animal should have good muscle mass (ribs, vertebrae, and hips
should not be easily visible).
•
Mammary Glands - If heavily lactating, the animal should not undergo surgery. Check to
see if milk comes out easily. If glands are hard, the animal may have mastitis.
•
Hydration Status - Lift up skin between shoulder blades. Tenting of the skin is abnormal
and indicates a level of dehydration.
•
Mucus Membranes - Gum and conjunctiva should be pink and moist.
•
Stool - Runny/watery diarrhea or loose stool with blood in it indicates that the animal is a
poor surgical candidate.
•
Heart and Lungs - Auscultation to evaluate status.
20
Sample Operations Manual
Veterinarian
Surgery Room Procedure
Once the assistant brings the patient into surgery, the surgeon verifies that:
•
•
•
Appropriate levels of oxygen and isoflurane are set.
Appropriate size re-breathing bag is attached.
The pulse oximeter is attached.
The surgeon ensures that the patient’s vital signs are within normal limits.
The surgeon “gloves in” using sterile technique.
The surgeon retrieves sterile surgical instruments necessary for the given procedure (spay or
neuter) from the instrument table, as well as sterile suture material and needle.
Administer vaccines post-op
1. Canine
— Rabies SQ– R
— Distemper SQ– L
— Kennel Cough (Intra-nasal)
1. Feline - administer all feline vaccines in leg (not foot), as low as possible
— FELV SQ– L rear leg
— FVRCP SQ– R front leg
Rabies SQ– R rear leg
Surgery Instructions
INTRODUCTION
While cost is consistently a factor at high-volume, high-quality, spay/neuter clinics, the quality of
our procedures must always come first. Quality is routinely defined as a degree of excellence
and it is with this concept in mind that we must address each aspect of patient care.
The quality of our procedures should encompass not only the surgery, but pre- and postoperative care as well. In order to implement the highest standards, each patient is monitored
with a pulse oximeter, the greatest attention to detail is given to the cleaning and sterilization of
surgical packs, and the use of cold sterile techniques has been eliminated from our protocols.
Additionally, each surgeon is required to cap, mask, and glove, and gown if deemed necessary,
for each patient.
Our standards provide for more than ensuring the well being of our patients; they enhance the
overall community perception of our program. Client and veterinary acceptance is a vital tool in
promoting the reputation and recommendation of high-volume, high-quality, spay/neuter
clinics. In addition, we constantly strive to improve our protocols, through reading current
publications and making and maintaining relationships with prominent faculty at research
institutions.
PROCEDURAL OVERVIEW
The surgical procedure itself should maintain a routine sequence of events to verify that each
patient is receiving the same standard of care. The surgeon should ensure that the technicians
follow a thorough protocol for surgical prep of the patients including but not limited to complete
clip, debris removal, surgical scrub, and bladder expression in females. As the surgeon
approaches the patient in the OR, a generally accepted practice would be to double-check
the status of the patient.
For example, the patient should be properly connected to the anesthesia machine, oxygen and
21
Sample Operations Manual
Veterinarian
isoflurane levels are appropriate and the pulse oximeter is operational. Also, it should be
confirmed that the patient is at the correct plane of anesthesia and the veterinarian must verify
sex of the patient, especially with cats. Finally, it should be noted that the patient is in proper
position for the surgery and that the light source is directed toward the incision site. At this point,
the veterinarian may glove-in and proceed.
The patient is draped in with “dealer’s choice”. This simply means that the surgeon might select
3 or 4 quarter drapes, with or without a fenestrated drape. Any combination of the above is
considered acceptable, with the most important feature being that there is an appropriate
barrier to prevent contamination of the surgical site.
The incision placement will obviously vary with both the sex and the species of the patient. We
have also determined that varying the incision placement depending on the age of the patient
can improve the efficiency of the entire procedure. Incisions in adult female dogs are generally
placed approximately 1 inch caudal to the umbilicus, while the incision in a pediatric female
dog would be placed approximately half way between the umbilicus and pubis. When spaying
an adult or pediatric cat, the incision is approximately half way between the umbilicus and
pubis.
In adult male dogs, the standard approach is a prescrotal incision. However, in pediatric male
dogs, the routine approach is scrotal. In fact, many spay/neuter veterinarians will actually
perform a “modified” scrotal castration in adult dogs that have non-pendulous scrotums. The
most important factor being that the same meticulous tissue handling is observed as in any other
procedure.
A tattoo is applied to all patients to ensure no future unnecessary anesthesia or surgery. We
perform a “scoring” procedure to accomplish the tattoo, by placing a small (~1cm) incision in
dermis near the incision site and applying ink (see illustration). We prefer paste vs. liquid ink in
that it is neater and stays in place better, and green is more obvious, especially on animals with
darkly pigmented skin.
CANINE OVARIOHYSTERECTOMY
The overall size of an incision will vary depending upon various factors, the most obvious being
the experience and/or comfort level of the surgeon. Repetition over time will tend to naturally
decrease the size of the incision to as little as 0.75cm in some patients. Another factor that aids
in efficiency is the use of the blade without the scalpel handle; even a practice as minute as this
saves time and creates less instrument cleaning.
Once the skin has been excised, a small amount of subcutaneous adipose tissue is removed to
improve visualization of the linea. This technique decreases the time necessary to enter the
abdomen, but it also decreases both the time and difficulty of the closure. With this approach,
the layers of linea, subcutaneous and subcuticular tissues can be more straightforwardly
apposed.
The linea is incised by utilizing the thumb forceps to tent the linea. The scalpel blade is
positioned sharp side up to puncture the linea and the incision is extended while using the
thumb forceps as a guide to safeguard the abdominal contents. Once entry is made to the
abdomen, the falciform ligament is dissected as necessary.
Due to the small size of the incision, it is typical practice to utilize a spay hook to locate and
exteriorize the first ovary. Learning to properly use a spay hook can occasionally be a challenge
in itself. In most cases the best technique for its use comes with trial and error. As a rule, the
thumb forceps are used to tense the body wall and the spay hook is inserted with the “hook”
toward the midline but held tightly against the body wall. (the Vet School “flip” or turning the
22
Sample Operations Manual
Veterinarian
instrument once inside has been ineffective for us). The spay hook is advanced to the dorsal
most aspect of the abdomen and lift between colon and bladder. The recommendation during
vet school has classically been to do the left side first since the ovary is more caudal and easier
to locate. However, we have found that going for the right ovary is many times easier to locate
with the spay hook because of the “tightness” of the uterine horn on that side. The ovary is
frequently higher on the right and therefore, more obvious tension is felt when the spay hook is
retracted. Anecdotally, we have noted that the horn and/or broad ligament is more easily
located in dogs when the spay hook is advanced caudally during the abdominal slide. In cats,
we have found that advancing the spay hook in a perpendicular fashion is more productive.
Usually, the surgeon will report the status of the uterus to the technician at this time.
At this point, the suspensory ligament is broken. This is accomplished by placing tension on the
ligament and applying digital pressure to tear. It is helpful to recognize the “groove” created
just below the border of the proper ligament. In rare cases you may need to nick the ligament
with a blade to facilitate its rupture. In order to isolate the ovary, create a window in the broad
ligament and place the appropriate size carmalt well below the ovary seated tightly. It is
extremely important to give yourself room for a “tag” above the carmalt. This will allow for
efficient ligature placement without slippage of the pedicle from the clamp. Place a clamp
above the ovary for hemostasis and while leaving the tag, cut the ovary away. Select
appropriate size suture and place Miller’s knot below carmalt. Double ligation may be necessary
in some large breed and/or pregnant or in-heat dogs. Use thumb forceps or hemostats to hold
tag to verify no oozing as carmalt is released. Follow the uterine horn to the bifurcation and
repeat the steps above on the opposite ovary.
It is more efficient to tear away the broad ligament when proceeding to each new step. This
prevents the necessity to go back and deal with it later. Occasionally, some bleeders may need
to be ligated in the broad ligament. This may be accomplished via suture or instrument tie.
Proceed to the uterine body and ensure a complete ovariohysterectomy is performed. This
eliminates the possibility of a stump pyometra and decreases the risk of adhesions to the
bladder. The uterine body is exteriorized to allow for proper placement of ligature(s). Place a
Miller’s knot securely above the cervix but below the bifurcation. In some in heat or pregnant
patients a modified transfixing suture may also be necessary. Keep in mind that in pregnant
patients when the uterus is removed, a natural reflex will be contraction of the tissue. Thus, the
knot security should be closely checked. In patients with extremely friable tissues, remember
that less may be more. Place clamp for hemostasis but not too close to ligatures to prevent
unnecessary distortion of tissue. Cut proximal to clamp and remove uterine body. Check for
oozing as the clamp is released and tension on uterine body is decreased. Complete a visual
sweep of the abdomen.
Perform closure of the linea making certain to acquire full-thickness bites through the linea. The
surgeon should select an appropriate suture size and close with cruciates. NO continuous
patterns in the linea. The cruciate is more efficient because it allows for effective apposition
without relying on one pattern to hold the entire incision closed, and is faster than simple
interrupted. The last cruciate should leave one tag long and one end as the “runner” to
proceed into the subcutaneous closure.
Perform closure of the subcutaneous and subcuticular tissues. The “runner” from the linea is used
to place a simple continuous closure of the subcutaneous tissue to the opposite end of the
incision tagging down to the fascia as you go. Then, the subcuticular tissue is closed with an
alternating continuous (railroading) back to the last tag of the linea. The runner is then tied off
to the last tag and the knot is buried. The knot is buried to prevent wicking and to ensure
appropriate skin apposition. The closed incision then has glue applied to the skin surface. The
glue should be applied on, NOT in the incision. Glue in the incision can lead to a foreign body
23
Sample Operations Manual
Veterinarian
situation and delay healing. Rolling of the incision (inverting the incision) can be helpful in
pediatrics to avoid issues with licking and wound contamination by creating a natural bandage.
Ensure patient has been removed from inhalation anesthetic and administer any
vaccines/injections intended for that patient.
FELINE OVARIOHYSTERECTOMY
The feline spay is performed in much the same way as the canine spay, with one notable
exception. We routinely use a method commonly referred to as the “pedicle tie”. Basically, an
instrument tie is performed on the ovarian pedicle similar to the technique many veterinarians
use in neutering a male cat. Upon isolation of the ovarian pedicle, the pedicle is feathered over
the surgeon’s finger to allow identification of the individual structures. The suspensory ligament is
located and torn/cut. The ligament can be cut with scissors or blade or torn with digital pressure
or a hemostat. A mosquito forcep is utilized to tie off the ovarian pedicle. (see illustration) One
“trick” for improving the efficiency of this technique is to clamp the forcep just enough to secure
the pedicle initially, and then “lock the box” completely as the tie is secured. This assists the
surgeon in sliding the knot off of the hemostat.
CANINE CASTRATION
In the adult male, the closed technique is the preferred method because it is more efficient
(saves time not to close tunic), there is less foreign material (suture) in closure and there is less
bleeding. The incision is prescrotal. We exteriorize the testicle (to minimize incision size, expose
from pole to pole vs. side to side) by stripping away excess tissue. Once exteriorized, we place
Miller’s knot while leaving a tag to ensure no slippage. One knot is usually sufficient. A modified
transfixing ligature (pass needle between the cord & vessel) can be used in place of the Miller’s
knot if preferred. This method is repeated on the opposite testicle. Closure can be
accomplished on males with a simple continuous pattern in the subcutaneous and subcuticular
tissues by using the “runner” method as utilized in the OHE. Glue is placed over the incision as
with the OHE.
In the pediatric male, one incision is placed over the scrotum along the median raphe. The
testicle is exteriorized and excess tissue is stripped away. Either the open or closed technique
work equally well in the pediatric male. A “figure 8” knot is placed and a tag left. This
procedure is repeated on the opposite testicle. The incision is closed with glue and the “rolling
technique” is used to prevent licking. A modified scrotal approach is sometimes used which is
essentially the same procedure, except the tunic is opened but the tunic is not removed from
the pole until after the tied cord/vessel is placed back into the tunic. The tunic is then stripped
of excess tissue and tied with a simple instrument tie. (See illustration). This technique is used on
large breed puppies and other non-pendulous scrotums.
FELINE CASTRATION
An incision is made over each testicle. Both testicles should be exteriorized before either is
removed to ensure the surgery doesn’t accidentally get half completed. Open or closed
techniques both work well. Open does not require closing the tunic and closed should ensure
the “double-pop” (an anecdotal description of the “feel” of the fascial breakdown allowing
complete exteriorization of the spermatic cord). Most surgeons commonly use an overhand
knot but I actually prefer a figure 8 knot. This knot is extremely secure and allows less chance for
the knot to slip. This technique is repeated on the opposite side and the incisions are left open.
24
Sample Operations Manual
Veterinarian
Appendix
Figure 8 Knot
Figure 8 Knot
11
12
12
13
13
25
Sample Operations Manual
Veterinarian
Feline
PedicleTie
Tie
FelineOvarian
Ovarian Pedicle
14
14
15
15
26
Sample Operations Manual
Medical Support Staff
Medical Support Staff
27
Sample Operations Manual
Medical Support Staff
Job Description & Responsibilities – Veterinary Technician
JOB TTITLE:
Veterinary Technician
JOB RELATIONSHIPS:
Reports to Head Veterinarian, provides supervision for all veterinary
assistants, kennel staff and volunteers.
JOB SUMMARY:
Responsible for daily care of all surgical patients, provide client services
and education
RESPONSIBILITIES:
Supervision and Client Services:
8. Supervise all kennel personnel and veterinary assistants.
9. Report employee or client problems to director.
10. Provide in-person and telephone client service and answer questions.
11. Actively promote spay and neuter, and educate clients on responsible animal ownership.
12. Actively support associate staff and volunteers; promote the development of skills related to
the advancement of our goals and mission.
13. Represent the clinic in a professional and courteous manner at all times. Provide quality
service to clients, volunteers, and staff, recognizing their individual contributions to the
success of our organization.
14. Maintain medical inventory and supplies.
Patient Care:
11. Triage all patients as they are checked in. Report health concerns to attending veterinarian.
12. Provide excellent patient care.
13. Assist veterinarians in surgery as needed.
14. Calculate and administer anesthesia to all surgical patients per anesthetic protocol.
15. Maintain all necessary drug logs and patient records.
16. Stay current in knowledge of emergency drugs and protocol.
17. Administer animal vaccinations, tests, medications and treatments as directed.
18. Participate on committees and special projects as assigned.
19. Other duties as assigned.
28
Sample Operations Manual
Medical Support Staff
Job Description & Responsibilities – Veterinary Assistant
JOB TITLE:
Veterinary Assistant/Medical Support Staff
JOB RELATIONSHIPS:
Reports to Veterinary Technician
JOB SUMMARY:
Responsible for daily care of all surgical patients, assist doctors and
technicians with surgical and anesthetic procedures, general
housekeeping
RESPONSIBILITIES:
General housekeeping
1. Perform daily cleaning of kennels, cages and public areas when necessary.
2. Stock prep room and operating room.
3. Spot clean throughout the day.
4. Clean prep room and operating room at the end of the day.
5. Wash and sterilize all surgical packs throughout the day.
6. Clean the kitchen.
7. Clean parking lot(s).
8. Other duties as assigned.
Patient Care
1. Triage all patients as they are checked in. Report health concerns to veterinary technician
or attending veterinarian.
2. Restrain all patients during anesthesia induction and intubation.
3. Monitor all patients on gas anesthesia.
4. Prepare patients for surgery as instructed.
5. Transport patients from prep room to operating room.
6. Assist veterinarians in surgery as needed.
7. Keep supervisor informed of animal behavior, health, or concerns.
8. Assist clients with necessary paperwork.
9. Monitor patients in recovery.
10. Assist transport driver with handling and unloading transport animals.
11. Provide excellent patient care.
12. Other duties as assigned.
Medical Support Staff Job Requirements
Client Education
1. Must be able to learn basic veterinary medical concepts including but not limited to
vaccine protocols and anesthetic risks
2. Must also be able to communicate basic veterinary concepts to owners and be able to
repeat information relayed by a veterinarian
3. Will be asked to take medical histories for surgical rechecks
4. Will be asked to communicate with the public on a daily basis in a professional manner
Animal Handling
1. Will be asked to handle (on average) 100 dogs and cats per day
2. Must be able to learn characteristics of animal behavior (for example: be able to identify
aggressive or fearful behavior)
3. Must be able to use appropriate safety equipment for fractious or feral animals (will train) –
the use of safety equipment is mandatory
29
Sample Operations Manual
Medical Support Staff
4. Must possess excellent reflexes
5. Should be able to identify own limitations and be willing to ask for help
6. Must become proficient at animal restraint for various procedures
Physical Requirements
1. Must be able to work standing or sitting for 8 or more hours
2. Must be able to lift and carry up to 50 pounds repeatedly throughout the day with help
3. Must be able to bend and kneel repeatedly
4. Must be able to see fine detail in a variety of situations
5. Must have good hearing including ability to distinguish changes in pitch
6. Must have reasonable degree of agility to move through tightly cramped areas in various
situations
7. Must have acceptable sense of touch and smell
8. Must have good range of motion in joints especially wrist, knees, elbows
9. Must have good range of motion in your back for instance twisting
10. Must be able to work in potentially extreme environmental temperatures
11. Must have acceptable sense of balance
12. Must be able to work and reach on hands and knees
13. Must be able to use a ladder and or step stool
14. Must possess excellent hand-eye coordination
15. May be asked to move large oxygen tanks
16. Must possess an acceptable degree of dexterity in hands and fingers
17. Must have good vision including peripheral vision, fine detail, distance, depth perception
and ability to focus
Emotional/Mental Requirements
1. Must be able to work under stressful conditions and work efficiently and effectively under
those conditions
2. Must be able to respond quickly to a variety of medical situations (with training)
3. Must be able to cope with death either due to surgical complication or euthanasia
4. Ability to rapidly and accurately process information
5. Ability to delegate tasks
6. Ability to recognize a need for assistance and ask for help
7. Ability to control instinct (for example: while restraining it is most often required to tighten grip
and NOT release the animal when they begin to struggle)
8. Ability to make decisions
9. Ability to cope with frustrating situations and remain calm
Potential and Prolonged Exposures
2. Prolonged exposure to various aqueous solutions including but not limited to dish soap,
chlorhexidine and spectra soap
3. Prolonged exposure to isopropanol, hydrogen peroxide
4. Potential exposure to formalin solution
5. Potential/Prolonged exposure to isoflurane gas
6. Prolonged exposure to quartenary ammonium cleaners and bleach
7. Prolonged exposure to pressurized steam
8. Potential exposure to sharps including needles and surgical blades
30
Sample Operations Manual
Medical Support Staff
Training Protocol
PHASE ONE
Receive and release
1. Speaking to the public
2. Admission form and release
3. Surgery and vaccine cost
• Female and male dogs- $0.00
• Female cats- $0.00
• Male cats- $0.00
• Vaccines- $0.00 each
4. General surgical procedure
5. Spay
• Procedure (what is removed, etc.)
6. Neuter
• Procedure (what is removed, etc.)
• Scrotal and pre-scrotal
7. Age/weight
8. Pain management
9. Post op instructions
10. Vaccines
11. Animal triage
• Identification of poor surgical candidates
• Owner explanation of poor surgical candidates
— URI of any magnitude
— Severely obese
— Too thin
— Too old
— Pediatric cryptorchid
— Suspicious mass
— Lactation
— Heart murmur
— Mange and effect of stress
• Identification of high risk surgeries
— Pregnant
— In heat
— Obese
— Too Thin
— Breed considerations (Boxer, etc.)
— Heartworm positive
— FIV/Felv positive
• Owner explanation of high risk surgeries
— Engorged vessels with heat
— Friable tissues associated with excess weight
• Accurate age determination
12. Name tags and cage cards
• First and last name
• Vaccines and abbreviations
13. Animal weigh-in and proper cage selection
• Importance of accurate weight
• Cage selection– separation of public and shelter
— Decreased risk for exposure to infectious disease
— Easier to load
31
Sample Operations Manual
Medical Support Staff
14. Release of animals to proper owner
• Double check animal ID (be aware of duplicate names)
• Incision inspection
— Spay
 Appearance of normal incision
 Gum color and overall demeanor
 Signs of complications
—
Pale
—
Lethargic
—
Weak pulses
—
Low temperature
— Neuter
 Appearance of normal incision
 Normal swelling
 Reasons to keep an animal and alert a doctor
 Removal of scrotal wrap
15. Relay information to owner upon release
• Explanation of minor surgical complications such as heat or pregnancy (any other
complications should be referenced to the head technician)
• Explanation of any concerns doctor may have
• Accurate response to owner questions or direction to proper person
Kennels
1. Cage cleaning
• Remove all newspapers, blankets, and organic debris
• Spray all surfaces with A-33 (sides, top, bottom and doors)
• Let sit for at least 10 minutes
• Scrub cage door with brush and wipe out all cages back to front
• Clean clipboard and cage card holder
• Place clean newspaper in cage
2. Run cleaning
• Remove blankets and organic debris from runs
• Scrub all surfaces with A-33 solution and water
• Let sit for 10 minutes
• Rinse out well and wipe dry
• Place clean sheet/blanket in run
3. Crate cleaning
• Remove newspapers and organic debris
• Spray all surfaces
• Let sit for 10 minutes
• Wipe all surfaces front to back
• Place clean newspaper in crate
4. Infectious diseases and their routes of transmission
Packs
1.
2.
3.
4.
5.
6.
7.
Proper maintenance of autoclave and ultrasonic cleaner
Washing surgical instruments
Complete knowledge of instruments and their function
Assembling surgical packs
Autoclaving all packs
Assembling and autoclaving surgical instrument trays
Assembling needle packs
32
Sample Operations Manual
8.
9.
10.
11.
Medical Support Staff
Cleaning endotracheal tubes
Disinfecting masks and muzzles
Proper folding of pack laundry
Weekly cleaning of autoclave
PHASE TWO
Canine Restraint
1. Proper restraint for SQ injection
2. Proper restraint for IV injection (induction)
3. Proper handling during loading and unloading
• Wear gloves
• Animal behavior signs
• Acceptable ways to handle aggressive or fractious animals
• Proper muzzle placement
Feline Restraint
1. Proper restraint for IM injection and venipuncture
2. Proper handling during loading and unloading
3. Net technique
4. Pour technique
5. Complete understanding and respect for feral cats and how to handle
Anesthesia Monitoring
1. Proper anesthetic levels for canines
• Maintenance– 2%
• Maximum– 5%
2. Proper anesthetic levels for felines
• Maintenance– 0.5%
• Maximum– 2% by mask (higher levels can cause respiratory distress)
3. Proper order for hooking up and disconnecting anesthesia
• Turn on Oxygen (1L)
• Turn on Isoflurane
• Connect hose to ET tube
4. Stages of anesthesia
• Stage I
— Analgesia
— Disorientation, fear
— Salivation
— Urination/defecation
• Stage II
— Delirium or excitement
— Struggling
— Irregular respiration
— Eyelids open and iris dilated
— Reflex vomiting
— Urination/defecation
• Stage III
— Plane I– pain responses still present, cardiovascular function minimally affected
— Plane II– respiratory rate decreased, cardiovascular function is mildly depressed
— Plane III– entrance into this plane is marked by the beginning of paralysis of the
intercostal muscles
33
Sample Operations Manual
5.
6.
7.
8.
9.
10.
Medical Support Staff
 Potentially dangerous level of anesthesia
 Respiratory depression is marked
 Cardiovascular function is noticeably depressed
— Plane IV– complete paralysis of intercostal muscles
 Passage into plane IV is marked by cessation of all respiratory effort and
dilation of the pupil
 Cardiovascular function is generally impaired and producing hypotension
and decreased cardiac contractility
• Stage IV– respiratory arrest followed by circulatory collapse (death ensues within one
to five minutes)
Recovery
• Ability to recognize a surgical complication
— Pale gums
— Weak pulses
— Rapid heart rate
— Abdominal distention
• Hematocrit
Components of gas anesthesia machines
• Flow meter– Oxygen
• Vaporizer– Isoflurane
• Pop off valve
• Flush valve
Proper maintenance of anesthesia machines
• Pressure checks
• Clean and inspect machine, hoses and bags
Pressure alarm– if pressure alarm sounds, unhook patient from anesthesia machine
immediately
Re-breathing bag size depending on the size of the animal
• Very large dogs– 3L
• Medium dogs– 2L
• Puppies, small dogs and cats– 1L
Soda sorb
• Function of soda sorb– absorbs exhaled carbon dioxide
• Frequency of change
Surgical Preparation of Dogs and Cats
1. ET tube
• Dogs - Never more than 3-cc
• Cats - cuffless tubes are used
2. Apply sterile eye lubricant– don’t leave uncapped
3. Administer pain medication
• Canine
— Morphine– IM injection in hind leg
 Proper administration
 Structure to avoid-sciatic nerve
4. Proper clipping of surgical area (enough for abdominal exploratory surgery)
5. Express bladder– general knowledge of anatomy (where bladder, spleen, etc. is located
and ability to locate on palpation
6. Scrub surgical area
7. Spray surgical area
8. Proper sterile transportation of animal into surgery
9. Complete understanding of sterile fields and surgical procedure
34
Sample Operations Manual
Medical Support Staff
Vaccine Protocol
1. Learn complete canine vaccine protocol
• Rabies vaccine at 12 weeks of age
• DA2PP (leptospirosis at 12 weeks) at 6-8 weeks of age, then repeated every 3 weeks
until 16 weeks of age
• Bordetella vaccine at 8 weeks of age, then repeated at regular vet’s discretion
• Heartworm test at 6 months of age
2. Learn complete feline vaccine protocol
• Rabies vaccine at 12 weeks of age
• FVRCP at 6 weeks of age, then repeated every 3 weeks until 16 weeks of age
• FELV at 9-12 weeks of age, then repeated in 3 weeks, then yearly
• FELV/FIV test at 8-9 weeks of age– any positive FELV or FIV test should be repeated in
3 months
ALL VACCINATION BOOSTERS SHOULD BE DISCUSSED WITH YOUR REGULAR VETERINARIAN AS
CURRENT PROTOCOLS CHANGE ROUTINELY.
Maintenance
1. Proper cleaning and maintenance of all machines in the prep area, including, but not
limited to:
• Ultrasonic cleaner
• Autoclave
• Microscope
• Centrifuge
• Pulse oximiter
PHASE THREE
Complete drug and emergency protocol
1. Canine and feline anesthetics and pre-medications
• Acepromazine
— Tranquilizer and pre-anesthetic
 Lowers respiratory rates
 Give SQ to dogs
 Give IM to cats with Buprenorphine
 Raises central venous pressure– should be avoided in patients with glaucoma,
etc.
 May cause bradycardia– contraindicated in boxers– very sensitive to
bradycardiac effects, may cause secondary heart block
 Allows for lower doses of general anesthetic
• Atropine/Glycopyrrolate
— Approved for use in cats/dogs
— Increases heart rate
— Counteracts bradycardia
• Buprenorphine
— Analgesic– give IM pre-med to cats
• Morphine – narcotic (opiate)
— Pre-emptive analgesic– used for the treatment of acute pain in dogs (always
given IM)
— Respiratory depression
— Sedation
— May cause constipation
— CNS effects
35
Sample Operations Manual
Medical Support Staff
Euphoria
Sedation and confusion
Cardiovascular effects– bradycardia
Increased bladder sphincter tone
Side effects:
 Drying of respiratory secretions
 Nausea and vomiting
 Hypothermia
 Over-dosage– give Naloxone
• Telazol- (Tiletamine/Zolazapam) injectable induction agent
— Indicated for restraint or anesthesia combined with muscle relaxation for surgeries
lasting less than 30 minutes
— Side effects:
 Hypothermia in small animals
 Eyes remain open– use sterile eye lubricant
 Tachycardia
 Emesis during recovery
 Excessive salivation
 IM injections are painful (cats)- dilute with sterile water to counteract
Proper administration of injections
• SQ – subcutaneous
• IV – intravenous
• IM – intramuscular
• IT – intratracheal
• IC – intracardiac
• SL – sublingual
Proper placement of IV catheters in routine and emergency situations
Complete emergency drug protocol
Emergency Drugs
• Epinephrine (Adrenalin)
— Increases heart muscle contractility
— Direct stimulation of the heart
— Used for cardiac resuscitation
— Antagonizes effects of histamine
— Raises systolic blood pressure
Emergency protocol
• Recognition of emergency situations
— Normal heart rate for dogs: (80–120) beats per minute
— Normal heart rate for cats: (130–200) beats per minute
— Normal respiratory rate for dogs: (15–30) breaths per minute
— Normal respiratory rate for cats: (20–30) breaths per minute
— Mucous membrane color and CRT
— Calculate accurate heart rate
— Check distal pulses
• Steps once an emergency is identified
— Call for a doctor
— Secure the airway
— Begin ventilation with Oxygen (turn off Isoflurane– flush machine)
— Get the crash cart
 Place animal in sternal recumbency
 Prepare the animal for intubation
— Properly bag the animal (positive pressure breathing)
—
—
—
—
—
2.
3.
4.
5.
6.
36
Sample Operations Manual
—
—
—
—
Medical Support Staff
 Never let pressure on anesthesia machine go above 20 cm of water
 High pressure alarm is set at 20 cm of water
Correctly perform CPR (chest compressions)
Correct use of stethoscope
Emergency drug dosages (see appendix)
Place an IV catheter
PHASE FOUR – Specific to Veterinary Technician
Patient Flow technician duties
1. Canine pre-medication (done by vet in morning until surgery begins)
• Canine pre-medication and dosages
• Correct dosages
• SQ injection about 20 minutes before induction
2. Canine induction
• Canine anesthesia
• Double-check dosage based on amount in syringe
• Locate cephalic vein and administer injection
3. Canine intubation– verify correct placement
4. Feline pre-medication
• Proper IM injection
• IM injection at least 30 minutes before induction
5. Feline induction
• Proper IM injection
• Path of sciatic nerve and proper injection site
• Administer injections to fractious cats (ability to use shield and net)
• Administer injections to feral cats (ability to use trap dividers)
6. Feline intubation
• Quickly intubate cats with or without lidocaine in routine or emergency situations
7. Patient Flow
• Acute awareness of general pace of doctors and staff
• Effectively direct staff to ensure efficient pace
• Memorization of emergency protocol and drug dosages
• Administer animal tests, medications, and treatments
• Effectively handle all re-checks as liaison between doctor and client
• Knowledge of infectious diseases and signs thereof
• Surgical protocol and aspects of all surgeries
Medical Records Technician
1. Complete knowledge of canine and feline anesthetics
2. Calculate and draw up all canine and feline pre-medications and anesthetics
• Canine anesthesia
— Telazol
 To reconstitute– add 5.0 ml sterile water
 To calculate dosage– multiply 0.0075 x animal weight in lbs.
— Canine pre-medication- Acepromazine
• Feline Anesthesia
— Telazol
 To reconstitute– add 5.0 ml sterile water
 To calculate dose– multiply 0.023 x animal weight in lbs.
— Feline pre-medication– Acepromazine (dilute 9:1) and Buprenorphine given IM
37
Sample Operations Manual
3.
4.
5.
6.
7.
8.
9.
10.
11.
Medical Support Staff
Complete daily drug log as required by DEA
Complete medical record (treatment sheet) on each animal
Complete post-op sheet
Compile and submit appropriate lists for each day
• Too young for rabies list
• No surgery list
Call no surgery owners and transports
• Effectively relay information about an animals condition to the owner
• Complete knowledge of medical protocol regarding no surgeries
Balance drug logs at the end of each day
File drug logs appropriately each month
Take all medical calls (head tech only)
• Complete knowledge of the [CLINIC NAME] protocol regarding treatment of animals
with surgical complications
• Identify a surgical complication vs. another illness
• Schedule rechecks and make sure a doctor is available
• Calculate antibiotic dosages per the doctor’s request
• Fill a prescription
Maintain and store all anesthetics daily as required
• Maintain and keep records of inventory
• Order all medical supplies
38
Sample Operations Manual
Standard Operating Procedures
Standard Operating Procedures
39
Sample Operations Manual
Standard Operating Procedures
Office Procedures
SCHEDULING APPOINTMENTS
Appointment Sheet
We provide written scripts for scheduling appointments. This ensures we provide the same
information to all clients.
We anticipate a 5% no-show rate and a 5% “declined for surgery” rate and schedule
accordingly.
Animals are transported to our facility for surgical sterilization Monday through Thursday. A 72hour notice of number of appointments from each transport is required. The three-day advance
notice allows us sufficient time to adjust public appointments.
Appointment Narrative
What type of pet do you have? (dog/cat, male/female)
Our earliest opening is M/Tu/Wed/Th/Fri, (month) (day). You’ll need to bring him/her in at
8:00am, and pick him/her up at 7:30am the following morning/5:00pm the same day (5:00pm
release on Fridays only).
How old is your dog/cat?
(Good opportunity to find out if pet is over 8 yrs (will need pre-operative blood work) or under 4
months (does not need to be fasted prior to surgery)
What is your name? What is the best phone number to reach you?
The night before surgery, you need to keep your pet indoors, and no food after 12:00 midnight
(remember, under 4 months old – do not need to fast!). Water is okay.
Does your pet have a current rabies vaccination?
If yes, please bring in his/her tag or certificate
If no, we will need to administer that vaccination while they are here
Our veterinarians highly recommend that your pet be vaccinated two weeks prior to surgery.
They will be around a lot of other animals and could be exposed to something (just like when
you send your kids to kindergarten). It takes two weeks for a vaccination to become fully
effective.
RECEIVING PATIENTS
Clients are asked to bring their animals at 8:00am each morning. Typically, we receive patients
from 8:00am until 9:00am daily. We make special allowances for clients with special situations.
Typically, admission of a patient is completed within 10 minutes of the client’s arrival. Our clients
are encouraged to pay at the time of admission, but we do accept payment when we release
the patient. We do not experience any problems with clients not returning for their pets.
We schedule a veterinary technician and an office representative to receive patients and
answer clients’ questions. The clients are instructed to complete the admission form. Upon
completion, the office representative reviews the admission form, advises each client on
vaccinations recommended for his or her animal, inquires about the purchase of supplemental
pain medication for the patient, checks for patient age and client signature, and collects the
fee.
40
Sample Operations Manual
Standard Operating Procedures
The client is then directed to the veterinary technician who confirms NPO status, determines any
medical concerns and provides identification for the pet. The questions asked are:
1. When was the last time (name) had anything to eat?
2. Was he/she indoors last night?
3. Any health concerns for him/her?
4. Is (name) on any medication, topical sprays, and ointments?
5. Has he/she received any medication and/or injections in the last month?
A member of our medical staff then receives the patient. Clients are provided a copy of their
admission form and requested to present that form when they return for their pet.
Admission forms are submitted to the office manager for entry into the computer database.
The post-op and treatment sheets are provided to the veterinary technician after the animal
information has been entered into the computer system. The office manager retains supportive
information and completes rabies certificates.
RELEASE OF PATIENTS
Our medical staff releases patients from 7:30am until 8:00am Tuesday through Friday, and again
at 5:00pm on Fridays. Post-operative instructions are reviewed verbally by the medical staff with
the clients and written instructions are also provided for each patient. We provide the clients
with a list of veterinarians in our community who provide free post-operative exams.
Clients are required to sign the clinic’s copy of the admission form for release of the patient. We
charge a $0.00 boarding fee for late pick-ups. Transport patients are returned with written postoperative instructions. The directors of the organizations scheduling the transports are trained to
review the instructions with the clients.
Surgical Program Requirements
All patients are given a physical exam before any injections are given:
1.
2.
3.
4.
5.
6.
7.
Auscult heart and lungs
Mentation/activity level
Body condition (Tuft’s animal care and condition scale)
Ocular and/or nasal discharge
Hydration status
Mucous membrane color
Any obvious abnormalities
If any abnormalities are noted, a complete physical exam is performed including temperature
evaluation and a decision is made as to the animal’s fitness for surgery. The following conditions
are examples of basis for rejection:
1.
2.
3.
4.
5.
6.
7.
8.
URI of any magnitude
Diarrhea
Vomiting
Moderate to severe skin disease
Ocular disease
Severe obesity
Poor body condition
Depressed attitude
41
Sample Operations Manual
Standard Operating Procedures
9. Sneezing/coughing
10. Heart murmur
Anything that might indicate an undiagnosed condition that may compromise the patient
during anesthesia, recovery, and/or healing will be considered reason for refusing surgery.
Although the mission of [CLINIC NAME] is to sterilize as many animals as possible, OHEs and
castrations are still elective procedures, and the individual animal’s well being comes first. If it is
in the animal’s best interest to have the surgery postponed, then arrangements are made to do
so.
Females that are in labor when they arrive are not subjected to surgery; at this point it is too late.
They are either sent home or given food, water, and a warm bed in a quiet environment and
allowed to give birth. Also, when a patient vomits undigested food, we will not do surgery on
that day. We may hold the animal over until the next day or reschedule, depending on the
circumstances.
Minor conditions that are noticed after induction are reported to the owners on the post
operative sheet, to be referred to an area veterinarian for treatment, and recorded on the
medical record. Cats have their ears checked by the staff during prep, and those that appear
to have ear mites may be treated. We have Doramectin for treating shelter, rescue, and feral
cats for ear mites. Most of these cats will never be seen by a veterinarian again, and we feel an
obligation to try to relieve them of such conditions while the opportunity exists.
Anesthesia is always to be avoided when not necessary.
All females over 16 weeks of age with unknown history must be shaved for signs of having
already been spayed (ABS). This includes shelter, rescue, and public animals that were stray.
Signs that indicate an ABS are: mid-line scar, tattoo, undeveloped nipples and vulva on an older
female. Keep in mind that very large scars may indicate a C- section, which may have left the
uterus intact. The whole picture must be considered in each case. All males must be checked
for two testicles. Cryptorchid animals less than 6 months of age should be rescheduled to allow
time for the testicle(s) to descend. Male cats without testicles should be checked for cheek
development and spines on the penis to determine if they have already been neutered (ABN).
Prior to performing a cryptchorid surgery, the surgeon should palpate the inguinal area.
Final pre-op considerations
Doctors need to check their patient’s anesthetic machine for correct set-up before beginning
each and every surgery. Mistakes are sometimes made and early detection saves lives. Doctors
also need to check feline patients’ sex before draping in - occasionally a male is prepped as a
female, and it is ultimately the doctor’s responsibility to prevent a male cat from having his
abdomen opened. Also, always check female patients for scars - although we try to identify
ABS’s prior to pre-med, they are occasionally missed by the staff, and the doctor should not
make the mistake of missing a scar before opening the abdomen on an animal that has already
been spayed.
Surgery
Five knots on all sutures. This technique has been proven to eliminate dehiscence, and must
always be used.
Large bites on the Linea alba: include at least 5 to 8 mm muscle tissue in the linea closure in cats
and up to 10 to 12 mm in large dogs. We never use simple continuous patterns in the linea-only
42
Sample Operations Manual
Standard Operating Procedures
cruciate or simple interrupted.
Large bites in the subcutaneous tissue. At least 3 layer closure-linea, SQ, and subcuticular plus
skin glue or staple/skin sutures.
No crushing sutures in closing - linea and subcutaneous tissue should be snugly and completely
closed but never crushed. Dead space should be closed and the SQ should be anchored at
least at both ends of the linea incision. Linea and subcutaneous tissue are closed with
absorbable suture.
Skin edges should be properly apposed - never allow one side to flap over the other or extend
above the other. Skin glue should not be applied between the skin edges but on the surface
after apposing the edges.
Miller’s knot - we use this knot on the ovarian pedicle and the uterine body. It is extremely
secure, minimizing complications. We may use a Miller’s knot in conjunction with a modified
transfixing ligature on the uterine body of a pregnant female with very large uterine vessels.
Modified transfixation ligature - We use this ligature on adult dog castrations. Canine castrations
are usually done as closed, except on older dogs where it is more difficult to separate the
epididymal ligament from the scrotum. If an open castration is performed, the vaginal tunic is
closed before placing the subcutaneous sutures.
Cat and puppy neuters, special technique: for neuters of cats and puppies under 12-14 weeks
of age, we tie the vas deferens and vessels off on themselves in a figure 8 knot. This knot is much
less likely to come untied than a simple square knot. A diagram is available illustrating this
technique.
In cryptorchid male dogs, we have found that a para median incision through the muscle layers
is preferable to a midline incision since it allows easier location and externalization of
abdominally retained testicles.
Surgery begins as early as possible in the shift, and doctors should be ready to perform surgery at
this time.
One doctor should arrive earlier in order to examine animals to be approved for surgery as they
are checked in. Doctors rotate recovery. This is an informal arrangement made each week.
Post-operative care
To calm patients recovering from surgery, environmental stress is reduced as much as possible.
Human activity is minimized and lights are kept off. The door to the cat room is kept closed.
Doors to the dog kennel should be kept closed at all times. Blankets should be hung over cages
of overly excited patients.
Pain Management
Veterinary medicine now requires a standard of care that incorporates pain relief for patients
undergoing painful procedures. OHE and castration are both known to be painful procedures
requiring treatment for pain. Pain is best controlled by prevention, and incorporating effective
drugs into the pre-medication or induction protocol can effectively prevent windup of
nociceptors and greatly reduce the level of pain experienced by the patient, as well as the
amount of drug needed during recovery. Our protocol reflects this data. The current
recommendations encourage the use of multimodal analgesic therapy. In fact, two to three
different forms of analgesics used in combination appear to be the most effective. Of those
43
Sample Operations Manual
Standard Operating Procedures
combinations, the most common ones utilized by boarded specialists are opioids with NSAIDS.
The recommendation that hydration status should be closely evaluated and that SQ fluids be
administered preemptively is appropriate. Specifically, in addition to Morphine for canine
patients and Buprenorphine for feline patients, supplemental pain medication is also utilized
(Meloxicam or additional Buprenorphine). Anecdotally, we have had serious post-operative
hemorrhaging resulting from the use of Ketoprofen in dogs, and no longer use this drug.
Supplemental Support
All pregnant females in the third trimester have an IV catheter placed and fluid therapy
administered
appropriately during the procedure. Ideally, fluids should be warmed. Any other patients
needing fluid therapy for any other reason also receive it in SQ or IV form. Immediately after
removal of the uterus, fetuses of third trimester pregnancies are removed from the uterus and
euthanized.
All cats, kittens, puppies, and small dogs get hot water bottles or rice bags, and “sugar lips”
upon removal from the surgery table. Anyone showing signs of hypothermia gets a heated rice
bag and extra blankets as needed.
Every patient gets a clean, appropriately sized blanket; the patient’s entire body should be
placed on his/her own blanket, not on the larger community blanket, which covers the entire
recovery area. The recovery area needs to be kept clean at all times.
Adult male dogs may receive a scrotal wrap to help reduce the incidence of scrotal swelling
post-op. The scrotal wrap is removed prior to discharge.
Antibiotics are available for patients that need them (pyometras, URIs that aren’t caught until
after induction, sterile field contamination, etc.).
Recoveries
Dogs stay in the recovery area until sternal or actively trying to get up. Cats stay until lifting their
heads. We have found that one of the best indicators of a normal recovery is level of
consciousness. Regardless of vital signs, an animal that is not regaining consciousness at a
normal rate should be closely assessed for post-operative hemorrhaging. If unresponsive to
stimulation, an abdominocentesis and hematocrit should be performed. The animal should be
re-anesthetized and explored if blood is obtained on the abdominocentesis and/or the
hematocrit level is of concern to the veterinarian. Patients are never left unattended until
consciousness has been regained - those that need to be monitored overnight for any reason
should be sent to a full service 24-hour facility for additional care, after the owners have been
contacted.
At the end of the day, all patients are given a final check by a doctor. They are assessed for
recovery status, signs of complications, and are ensured of a clean, dry, warm bed. Male cats
are especially prone to urinate on their beds during recovery. No patient should ever be made
to lie in a soiled bed overnight.
Cats having a rough recovery from Telazol may receive a low dose of sedative to smooth out
their recovery and prevent self-injury. The staff gives a small amount of dry food to recovered
adult patients at the end of the day. Pediatrics who are fully awake are given a small amount of
dry food and water. The water is always removed at the end of the day, not left in the kennel
overnight.
44
Sample Operations Manual
Standard Operating Procedures
Re-checks:
When possible, doctors should try to see their patient’s re-checks and contact the owners of
their patients. This is not always possible with part-time doctors, so we try to assist when needed.
Health Exam for Dogs and Cats
1. Eyes - Look for signs of discharge from the eyes. This is an indication of an upper
respiratory infection.
2. Nose - Look for signs of nasal discharge. This is also an indication of an upper respiratory
infection.
3. Body Condition - The animal should have good muscle mass (ribs, vertebrae, and hips
should not be easily visible).
4. Mammary Glands - If heavily lactating, the animal should not undergo surgery. Check to
see if milk comes out easily. If glands are hard, the animal may have mastitis.
5. Hydration Status - Lift up skin between shoulder blades. Tenting of the skin is abnormal
and indicates a level of dehydration.
6. Mucus Membranes - Gum and conjunctiva should be pink and moist.
7. Stool - Runny/watery diarrhea or loose stool with blood in it indicates that the animal is a
poor surgical candidate.
8. Heart and Lungs - Auscultation to evaluate status.
Surgery Room Procedure
Once the assistant brings the patient into surgery, the surgeon verifies that:
1. Appropriate levels of oxygen and isoflurane are set.
2. Appropriate size re-breathing bag is attached.
3. The pulse oximeter is attached.
The surgeon ensures that the patient’s vital signs are within normal limits.
The surgeon “gloves in” using sterile technique.
The surgeon retrieves sterile surgical instruments necessary for the given procedure (spay or
neuter) from the instrument table, as well as sterile suture material and needle.
Administer vaccines post-op
• Canine
— Rabies SQ– R
— Distemper SQ– L
— Kennel Cough (Intra-nasal)
— Feline - administer all feline vaccines in leg (not foot), as low as possible
— FELV SQ– L rear leg
— FVRCP SQ– R front leg
— Rabies SQ– R rear leg
45
Sample Operations Manual
Standard Operating Procedures
AM / PM Procedures
AM PROCEDURES
•
•
•
•
•
•
•
•
Run autoclaves
Load cats into carriers
— Check each incision, bring concerns to doctor
— Double check collar matches name on carrier
Clean dog and cat kennels
Set up Prep Room
— Put out clippers
— V-tray
— Pee bowl
— Eye lube
— Scrub buckets ready
Set up OR
— Buckets for instruments (spectra soap), needles (spectra soap), and tubes
(dilutechlorhex)
— Put out ink caps
— Turn on oxygen
— Turn on scavenger
— Set up recovery area
— Turn on surgery lights
— Plug in heated V-trays
— Set up extras tray and needles pack
— Open surgical blades onto needles pack
— Tip suture (doctor)
Set up Pack Area
— Fill sonicator with enzyme cleaner
— Deflate and sort tubes
— Fill bucket with A-33 for masks and muzzles
Set up Tech Table
— Get drug logs out
— Get drugs from safe etc
Start Laundry
PM PROCEDURES
•
Prep Room
— Clean prep tables
— Fill scrub buckets
— Fill all spray bottles
— Clean clipper blades
— Turn off all oxygen and flush lines
— Turn off scavenger
— Fill isoflurane
— Empty trash
— Vacuum and mop
— Empty vacuum
•
OR
— Turn off oxygen and flush lines
46
Sample Operations Manual
—
—
—
—
—
—
—
—
—
Standard Operating Procedures
Clean tables
Throw out ink caps
Fill isoflurane
Unplug heated V-trays
Sweep and mop
Throw out trash
Turn off surgery lights
Wash out sugar lips container
Throw out old bags of fluids (3 days or older)
•
Packs
— Finish washing all instruments and tubes
— Make all packs
— Assemble extras tray and needles packs
— Rinse all masks and muzzles and hang to dry
— Wash and disinfect pee bowls
— Empty sonicator (as needed)
— Lint roll and fold all pack laundry
— Load autoclaves
•
Rest of Clinic
— Feed dogs and check to make sure all animals are in clean cages
— Sweep and mop entrance area and hallways
— Clean bathroom/s and empty trash
— Empty all trash in clinic
— Turn off all lights, washers and dryers and coffee pot
— Turn off autoclaves/not running
EXTRA DUTIES
—
—
—
—
—
Change soda sorb as needed and perform pressure checks on machines
o OPEN POP OFF VALVE!
Soak and rinse all reservoir bags and hoses in dilute chlorhexidine solution for 10 minutes
Wash walls, anesthesia machines, table bases, surgery lights
Organize all shelves
Sweep and mop laundry room/area, wash down washer and dryer, empty trash
Surgical Pack Procedures
COMPLETE LIST OF INSTRUMENTS USED:
1. Olsen-Hegar needle holders
2. Thumb forceps
3. Towel clamps
4. Metzenbaum scissors
5. Straight carmalts
6. Curved carmalts
7. Curved hemostats
8. Straight hemostats
9. Straight crile
10. Spay hook
11. 4x4 gauze squares
12. Fenestrated drape
47
Sample Operations Manual
Standard Operating Procedures
13. Blue surgical towels
14. Re-usable cloth pack wrap
DUTIES
1.
2.
3.
4.
5.
6.
Wash and sonicate surgical instruments
Assemble packs and autoclave
Tend to pack laundry
Clean endotracheal tubes
Prepare hot water bottles for OR person
Maintain clean cat masks and muzzles
INSTRUMENT CLEANING
• Take all instruments from surgery (soaking in spectra soap solution)
• Scrub instruments with soft bristled brush (NEVER use wire brushes, they will damage the
instruments)
• Use cleaning solution of spectra soap
• Pay close attention to hinged areas (boxes) and ridges (blood and tissue collect here)
• Rinse in clean water
• Place instruments in ultrasonic cleaner with enzyme cleaner for NO LESS THAN 10 minutes
• Do not overload
• All instruments should be BELOW the surface of the enzyme cleaner
• Rinse with clean water, blot dry with towel, spray on instrument milk, and sort (instrument
milk should be left on instruments)
SURGICAL PACK ASSEMBLY
*The contents of the following packs may change per your surgeon’s request/preferences.
Starting with pack wrap and one bottom towel…
FEMALE DOG PACK (FD)
2 carmalts (preferably one straight and one curved)
1 spay hook
1 crile
1 curved hemostat
1 needle holder
1 thumb forcep
1 pair of tissue scissors
2 towel clamps
FEMALE CAT PACK (FC)
1 Carmalt
1 spay hook
1 crile
1 straight hemostat
1 curved hemostat
1 thumb forcep
1 pair of tissue scissors
1 needle holder
2 towel clamps
*MD and FD packs are priority wrt towel clamps, if not enough, leave out of this pack first
48
Sample Operations Manual
Standard Operating Procedures
MALE DOG PACK (MD)
1 x-large crile or carmalt
1 needle holder
1 thumb forcep
2 towel clamps
All of the packs described above receive (exactly) 5 pieces of gauze, a steri strip and 3 towels
on top
MALE CAT PACK
(assembled using a wrap and placing contents between two “bottom” towels)
10 hemostats (usually curved)
10 pieces of gauze
10 blades unopened (opened blades will dull with autoclaving)
Packs should be wrapped tight enough so that when thrown against the wall they do not come
open.
Place a small piece of autoclave tape on the outside and mark accordingly (i.e. FD, FC, MD)
IMPORTANT INFORMATION ABOUT PACK WRAPPING
• If a wrap has a hole in it (even one side, even if it is small) THROW IT OUT
• A hole in the material will allow microorganisms from the environment to enter the
inside of the pack and contaminate it
• If a towel has a hole in it THROW IT INTO THE RAG PILE
• A hole in the towel may allow hair from surrounding area of surgical field to
contaminate incision site
• A hole may allow microorganisms from the environment to enter the surgical field
• Blood should NOT be present on any pack wraps, towels or instruments assembled
into surgical packs
• While blood can technically be sterilized in the autoclave, IT MAY FLAKE OFF AND
FALL INTO THE SURGICAL OPENING
• It will become a foreign object in the patients abdomen possibly creating
complications for the patient
• Hair and fuzz should be removed from towels and pack wraps before assembly
• Hair and fuzz may become deposited unknowingly into the abdomen and create
complications for the patient
• Use of the lint roller prior to assembly helps reduce the amount of hair and lint on
pack laundry
• DO NOT ratchet instruments closed before autoclaving
• You are not able to ensure the sterility of the metal-to-metal contact point (the steam
will not be able to reach the area)
• Water trapped in the ratchet grooves may increase the chance of rusting thereby
decreasing the life of your instruments
• Remove all indicator and masking tape prior to washing pack wraps
• Successive cycles of washing and drying may leave a permanent sticky residue that
may pick up hair and fuzz from the environment
SPECIALTY PACKS
Instrument Trays/Extras Tray
* The contents of this tray may vary, its purpose is to provide the surgeons with extra instruments,
gauze etc. There should be two of these in case one is contaminated during the day. Instrument
49
Sample Operations Manual
Standard Operating Procedures
trays and their lids should be autoclaved separately. Remember to include a steri strip and
autoclave tape for each.
• Contains a couple of each instrument (no more than 5 except for hemostats/carmalts)
• A small stack of gauze (about 20 pieces, any more will be wasted)
• 2 towels
• 1-2 fenestrated drapes
• a steri strip
Needle pack
Ensure that there is a variety of needle sizes, a small stack of gauze and steri strip
There should be at least 2 packs in case one is contaminated during the day
Specialty packs
Examples:
-
Gauze pack
Laporatomy sponges
Retractors
Suction components
Outside tape should contain
• Identification of the contents
• Date (if pack will not be used daily)
• Initials of preparer (optional)
DO NOT forget the steri strip or the autoclave tape on the outside in these packs
Should be rewrapped and sterilized every three months
USING AUTOCLAVE SLEEVES/POUCHES (some tips that may prove useful)
1. Place all instruments and gauze inside being careful not to puncture plastic front or
paper backing
2. The bag is its own indicator (locate indicator on outside of bag to familiarize yourself)
3. Once instruments are placed inside fold over ends that are not factory sealed and tape
all the way across and fold tape over each end (some bags have their own sealing
flaps)
4. When autoclaving place pouches plastic side down on metal trays
5. If placed paper side down the moisture has a tendency to weaken paper and allow
instruments to poke holes into pack and thereby contaminate the pack
6. DO NOT remove/touch packs until completely dry (same reason as above)
7. Sometimes the plastic will singe on the metal tray while heating in the autoclave,
however this occurs less frequently than #5
AUTOCLAVING
2. Follow instructions set forth on your autoclave
3. Packs must be at 2500F for no less than 30 minutes
4. The steri strip DOES NOT indicate sterility, it ONLY indicates that the autoclave hit the
specific temperature and NOT that it stayed there for the required length of time
5. The steri strip however DOES indicate an unsterile pack
6. The red pointer located in the temperature/pressure window indicates that the
autoclave has reached a specific temperature. It will not move on its own, therefore it is
helpful in assessing whether or not the autoclave is losing pressure during a run. Check
the autoclave several times during its run to ensure it is maintaining pressure and
temperature for the entire run. The red pointer should be returned to zero after each run.
7. Once the autoclave has finished running and the pressure returns to zero, open the
autoclave and pull out the trays to allow the packs to air dry.
50
Sample Operations Manual
Standard Operating Procedures
8. Do not touch the packs while they are wet. Do not place wet packs on tables. The wet
material will wick microorganisms from the immediate environment into the interior of the
pack and contaminate the pack. (This guideline should be adhered to whenever
possible.)
CLEANING ENDOTRACHEAL TUBES
1. Allow all tubes to soak in a dilute chlorhexidine solution for at least 10 minutes. It is helpful
to take tubes from OR or soak for 10 minutes at pack area since you may not know when
the last tube was placed in the bucket.
2. Remove tubes and inflate each one. Inflate enough to remove all creases in the cuff but
do not over inflate. Over inflation leads to unnecessary stressing of the plastic and will
decrease the useful lifetime of the cuff/tube.
3. Using either a soapy chlorhex solution or dish soap clean the outside of the tube and
ensure all mucous etc is removed from the cuff and the hole near the end of the tube.
4. Use the special tube brushes to clean the inside of the tube. Insert brush into both ends to
ensure the entire tube has been cleaned. Do not use the instrument brushes on tubes - it
negates the effect of disinfecting them before cleaning.
5. RINSE WELL with clean water.
6. REMEMBER YOUR PATIENT BREATHES THROUGH THESE TUBES!
7. Hang to dry and deflate before sorting into appropriate bins.
8. If water has collected inside the cuff, throw the tube out.
9. If the cuff does not hold air, throw the tube out.
10. This is the best time to test all ET tubes for defects.
MISCELLANEOUS
Remember when making hot water bottles that “Wet is not Warm”. This means you should dry
the outside of the bottles off before placing them next to a patient. Also ensure that the bottle
does not have direct contact with patient to ensure against burns.
Blades can be opened en masse onto the needles pack prior to surgery following standard
sterile technique.
Disease Control Procedures
The first priority of disease control is to keep the patients that are in our care in clean and tidy
cages. This also means keeping their surroundings clean and cleaning previously used cages to
prevent cross-contamination. The daily duties of the disease control person include (but are not
limited to) the following:
Daily Tasks
1. Clean and disinfect all cages.
2. Wash, dry, and fold all laundry.
3. Sweep, mop, and disinfect the kennel area and cat room (this includes under all cage
banks).
4. Clean bathrooms.
5. Empty all trash (kennel, cat room, waiting area, and front office).
6. Clean all windows and doors.
7. Sweep, mop, and disinfect the waiting area (this needs to be done as soon as receiving
is complete).
8. Clean the front office. First impressions are very important, so make sure this area is
always clean and tidy.
51
Sample Operations Manual
Standard Operating Procedures
9. Periodically check occupied cages and clean if necessary.
10. Clean kennel dishes.
Weekly Tasks
1. Dust the mini blinds in the front office.
2. Sweep, mop and straighten laundry room(s).
3. Straighten all newspaper boxes.
4. Run errands for clinic.
5. Purchase kennel inventory items.
Cage Cleaning
Dog Cages
• Remove all newspapers, blankets, and organic debris.
• Spray all surfaces with dilute clorox 1:32 (this includes all sides, top, bottom, and
cage doors).
• Let sit for 10 minutes.
• Scrub cage door with brush and wipe out all cages back to front.
• Clean clipboard and cage card holder.
• Place clean newspaper in cage.
Cat Cages
• Remove all newspapers, blankets, and organic debris.
• Spray all surfaces with Trifectant (this includes all sides, top, bottom, and cage
doors).
• Let sit for 10 minutes.
• Scrub cage door with brush and wipe out all cages back to front.
• Clean clipboard and cage card holder.
• Place clean newspaper in cage.
Cleaning the Runs
1. Remove all newspapers and blankets.
2. Scrub all surfaces with a solution of dilute clorox 1:32.
3. Let sit for 10 minutes.
4. Rinse thoroughly and wipe dry.
5. Place clean sheet in run.
Crate Cleaning
Dog Crates
•
•
•
•
•
Cat Crates
•
•
•
•
•
Remove all blankets and organic debris.
Spray all surfaces with dilute clorox 1:32.
Let sit for 10 minutes.
Wipe all surfaces front to back.
Place clean newspaper in crate.
Remove all blankets and organic debris.
Spray all surfaces with Trifectant.
Let sit for 10 minutes.
Wipe all surfaces front to back.
Place clean newspaper in crate.
CANINE DISEASES/VACCINES
Canine Distemper
This potentially fatal disease is caused by a virus and is spread through contact with the bodily
52
Sample Operations Manual
Standard Operating Procedures
secretions of infected puppies or dogs. Signs may include diarrhea, fever, upper respiratory signs
including runny eyes and nose, and neurological signs including muscle tremors and seizures. The
distemper vaccine provides good protection when given appropriately to puppies older than six
weeks of age. The distemper vaccine is acombination vaccine, which also provides protection
against Parvo virus, infectious canine hepatitis, para influenza virus and other diseases
depending on the product.
Parvo Viral Enteritis
This is a commonly occurring viral disease that primarily affects unvaccinated puppies and is
often fatal without treatment. Affected canines usually present with large amounts of watery or
bloody diarrhea, vomiting and severe dehydration. Parvo virus is highly contagious. It is spread
by contact with the feces of infected patients and can live in the environment for months to
years. Again, appropriate vaccination of puppies is very effective in preventing this disease.
Infectious Canine Hepatitis
Another disease caused by a virus, hepatitis is generally spread through contact with infected
urine or feces. The virus enters the tonsils and lymph nodes where it reproduces before attacking
the liver and intestine. Signs include fever, tonsillitis, ocular and nasal discharge, depression and
occasionally sudden death, especially in puppies. In patients that recover, a bluish discoloration
may be noted on the surface of the eye. This disease may affect whole litters of puppies.
Canine Para Influenza
This is one of several viruses that contribute to infectious tracheobronchitis, also known as kennel
cough. Dogs affected have a dry hacking cough and ocular and nasal discharge. Although the
para influenza portion of the distemper vaccine cannot prevent kennel cough, it can decrease
the severity of clinical signs in dogs that are infected.
Rabies
This very serious viral disease affects most warm-blooded animals including cats, dogs and
humans. The virus is present in the saliva of infected animals and is transmitted through bite
wounds. Once inside the body, the virus attacks the nervous system, eventually causing death.
Once clinical signs occur, the disease is almost always fatal. Since rabies is maintained in
populations of wildlife, such as skunks, foxes, bats and raccoons, it is a persistent danger to
unvaccinated companion animals. For this reason, most states require, by law, regular routine
vaccinations against rabies for all dogs and cats. Any person who is bitten by a strange animal
should seek medical attention immediately.
Leptospirosis
Causes a bacterial infection that affects several parts of the body. Domestic animals transmit
the bacteria through urine to both animals and humans. The illness occurs most commonly in the
tropics and can be treated with antibiotics.
FELINE DISEASES/VACCINES
Feline Distemper
This disease, also known as panleukopenia, is caused by a virus that spreads easily in groups of
unvaccinated cats, affecting young kittens most severely. The virus can enter the body by being
inhaled or swallowed, or it may enter through flea bites. It then attacks the intestine, causing
vomiting and diarrhea. It can also enter the bone marrow, causing decreased numbers of white
blood cells in the blood stream and as a result decreasing the cat’s ability to fight infection. This
disease can progress rapidly to shock and death. The feline distemper vaccine is very effective
in preventing this disease. Like the canine distemper vaccine, the feline distemper vaccine is a
combination vaccine and includes vaccines against Feline Viral Rhinotracheitis and
53
Sample Operations Manual
Standard Operating Procedures
Calicivirus.
Feline Viral Rhinotracheitis and Calicivirus
These viruses cause diseases of the upper respiratory system of cats. FVR causes sneezing, runny
eyes and nose and may cause pneumonia and death in kittens. Calicivirus causes ulcerations in
the mouth and nose. Both of these viruses may cause chronic, recurring disease.
Feline Leukemia (FELV)
This viral disease can present with many different signs including runny eyes and nose, difficulty
breathing, weight loss, lack of appetite and depression. Though often fatal, cats may be
infected for long periods of time without showing signs of illness. The virus may be detected
easily using a readily available blood test. Though vaccinations provide good protection against
FELV, they are not 100% effective at this time. FELV positive cats should not be housed with
healthy cats, even if they have been vaccinated against FELV. Because FELV affects a cat’s
immune system, FELV positive cats often develop opportunistic infections to which healthy cats
are resistant. It should be noted that an FELV-positive cat may not be protected against other
infectious diseases, including rabies, by vaccinations.
Rabies
This very serious viral disease affects most warm-blooded animals including cats, dogs and
humans. The virus is present in the saliva of infected animals and is transmitted through bite
wounds. Once inside the body, the virus attacks the nervous system, eventually causing death.
Once clinical signs occur, the disease is almost always fatal. Since rabies is maintained in
populations of wildlife, such as skunks, foxes, bats and raccoons, it is a persistent danger to
unvaccinated companion animals. For this reason, most states require, by law, regular routine
vaccinations against rabies for all dogs and cats. Any person who is bitten by a strange animal
should seek medical attention immediately.
PARASITES
Roundworms– may stunt growth
1. Transmission– contact with soil contaminated with infected feces or ingesting host with
larvae in tissues (often transplacental transmission from mother)
2. Typical patient– puppies/kittens, thin with potbellies, anemia
3. Signs– diarrhea, poor hair/coat, pot-belly, if infection is severe may enter stomach where
they may be vomited
4. Method of detection– fecal float
5. Treatment– Pyrantel
6. Environmental control– preventative de-worming and remove infected fecal material
Whipworms– may cause colonic inflammation, bleeding and intestinal protein loss
1. Transmission– feces or soil (fecal-oral)
2. Typical patient– dog
3. Signs– sometimes none, bloody mucus, greenish diarrhea, CNS signs
4. Method of detection– fecal float
5. Treatment– Panacur or Drontal Plus
6. Environmental control– difficult to eliminate, remove dog from infected environment
Hookworms– may cause life threatening blood loss or iron-deficiency anemia, may stunt growth
1. Transmission– fecal-oral (soil or feces) or direct penetration in pads of animal
2. Typical patient– dogs and cats (dogs more affected than cats)
3. Signs– frank fecal blood, diarrhea, anemia, failure to thrive, very thin animal with potbelly
4. Method of detection– fecal float
54
Sample Operations Manual
Standard Operating Procedures
5. Treatment– Pyrantel
6. Environmental control– preventative de-worming, remove animal from infected area
Tapeworms– rarely pathogenic in small animals
1. Transmission– ingestion of infected flea
2. Typical patient– dogs or cats with fleas
3. Signs– see tapeworm segments on feces or the perineal area
4. Method of detection– visible segments
5. Treatment– Drontal
6. Environmental control– flea prevention
Coccidia (protozoa)
1. Transmission– fecal-oral
2. Typical patient– puppies/kittens
3. Signs– mild to severe diarrhea, sometimes with blood
4. Method of detection– fecal float
5. Treatment– Albon
6. Environmental control– remove infected feces
Giardia (protozoa)
1. Transmission– ingest giardia cysts shed from infected animals (beavers) often via water
2. Typical patient– dogs that live near streams, hiking, or on farms
3. Signs- “cow patty” diarrhea without blood or mucus, may experience weight loss
4. Method of detection– smear, snap test
5. Treatment– Panacur/ Metronidazole
6. Environmental control– don’t allow animal to drink from streams or standing water
Budget Process & Financial Guidelines
Designing a Budget
Reference the Humane Alliance budget
Financial Controls
Develop an accounting control system to reduce errors. Areas to focus include: cash receipts
cash disbursements, petty cash, payroll, grants, fixed assets, check issuance, deposits, and
transfers. Also, you will want to set up a policy for salary levels, vacation, overtime,
compensatory time, benefits, grievance procedures, severance pay, evaluation, and other
personnel matters. As your organization changes, you will want to review your budgeting
procedures and update your financial controls.
Basic Financial Reports
Financial reports should be performed monthly, quarterly, and annually. Three commonly
implemented reports are balance sheets, income statements, and cash flows. In a small nonprofit organization the board treasurer or outside accountant would work closely to the clinic
director and prepare the financial information. The clinic director should review all reports prior
to presenting them to the board members.
Audits
The purpose of audits is to test the accuracy and completeness of the organizations financial
statements. Audits must be performed by a certified public accountant (CPA). The auditor will
request information including: bank balances, contribution amounts, conditions and restrictions,
55
Sample Operations Manual
Standard Operating Procedures
contractual obligations, and monies owed to and by your organization. Some non-profit
organizations are legally required to obtain audits. You will need to contact your Secretary of
State for regulations on raising money; since some states require an audit once you hit a specific
amount.
Outsourcing
We recommend getting a bookkeeper/ accountant. Outsourcing your financial information will
save you time. Accountants will help with financial statements, annual audit reports, cash flow,
taxes, reporting, and loan or capital requirements.
Important Phone Number, Websites, & Resources
Insert phone numbers, websites, & resources here
56
Sample Operations Manual
Risk Management
Risk Management
57
Sample Operations Manual
Risk Management
Insurance Guidelines
Creating a 501(c)(3) Nonprofit in North Carolina (state guidelines vary)
• Establish a Board of Directors. If you are sure a new organization is really needed, the next
step is to establish a Board of Directors. North Carolina law requires only one board member,
but best practices recommend that you have at least five; a minimum of seven is preferable.
o
As you recruit board members, make sure they are aware of their roles and
responsibilities. These include but are not limited to: selecting and reviewing the
performance of the chief executive; recruiting new board members; ensuring
effective organizational planning; evaluating organizational performance; providing
financial oversight; and ensuring legal and ethical integrity.
o
A first priority for the board of directors is to clarify the organization’s mission and
purpose. The board must realistically determine both its short- and long-term goals by
identifying who the organization will serve, clarifying what values will drive the
organization, and planning for how the organization’s mission may evolve over time.
Steps to Establish Your Nonprofit
• Before applying for tax-exempt status, you need to create organizational bylaws. It’s helpful
to review those of existing nonprofits and to have a lawyer review them before they’re
finalized.
•
Incorporate as a nonprofit corporation by registering with the N.C. Department of the
Secretary of State. For forms and free information, including guidelines for incorporating, call
888/246-7636 or 919/807-2225, or visit www.secretary.state.nc.us/corporations.
•
Apply for a Federal Employer Identification Number (FEIN). File Form SS-4 (available at
www.irs.gov/pub/irs- pdf/fss4.pdf) with the IRS -- even if your nonprofit doesn’t have any
employees. The IRS uses this number to track reports and your tax-exempt application.
•
The next step is to apply to the IRS for tax-exempt status as a 501(c)(3) nonprofit by filing Form
1023. The form and instructions are available at www.irs.gov/charities/index.html or by calling
800/829-3676. We strongly recommend you have an attorney or CPA familiar with nonprofit
tax law review your application before final submission. You will hear from the IRS in 3-24
months after submitting Form 1023.
•
Ordinarily, there is no need for a new nonprofit to apply for an exemption from the state
income and corporate franchise taxes. Rather, the N.C. Secretary of State will notify the N.C.
Department of Revenue after an organization registers as a nonprofit. The Department. of
Revenue will then contact the nonprofit to obtain additional information and begin the
process. While nonprofits must pay sales and use taxes at the point of purchase, most can
obtain a semi-annual refund by filing a Form E-585 with the Department of Revenue. For
more information or to obtain Form E-585, visit www.dornc.com or call 877/252-3052.
•
You are required to carry workers’ compensation insurance once you have three full- or parttime employees and/or corporate officers. Contact the N.C. Industrial Commission (919/8072500, (www.comp.state.nc.us) for information on how to obtain coverage.
•
File with the N.C. Employment Security Commission (919/733-7156, www.ncesc.com) for
unemployment taxes when you have at least four full- or part-time employees working a
total of 20 weeks in one calendar year. Apply for an Unemployment Tax Number and then
file the Employer’s Quarterly Tax and Wage Report.
58
Sample Operations Manual
Risk Management
•
Apply for local property tax exemption by contacting your local County Tax Office. Even if
property tax exemption is granted, it is still necessary to file a complete property listing by
January 31.
•
Finally, make sure you apply for a Charitable Solicitation License through the Solicitation
Licensing Branch of the N.C. Department of the Secretary of State (888/830-4989 or 919/8072214, www.secretary.state.nc.us/csl) if you will be raising $25,000 or more in one calendar
year.
Ongoing Legal Requirements
• File Form 8734. The initial letter you receive detailing your 501(c)(3) status is an “advanced
ruling” only. To maintain this status, your organization must submit Form 8734 to the IRS within
90 days of the end of your advanced ruling period (this date will be listed on your IRS
determination letter).
•
File IRS Form 990. Any nonprofit with annual gross receipts of $25,000 or more must file a Form
990. You must refile Form 990 annually within 4.5 months after your fiscal year ends. Beginning
in 2008, nonprofits with receipts under $25,000 are required to electronically file form 990-N.
The forms are available on the IRS website, www.irs.gov/charities/index.html. Call 877/8295500 or your CPA for details.
•
Renew your organization’s Charitable Solicitation License. The license must be renewed
annually, within 4.5 months after the end of your fiscal year.
•
Collect sales tax on items sold. If your nonprofit sells retail items, register with the N.C.
Department of Revenue for a Certificate of Registration, file the returns, and pay the tax due
on a quarterly or monthly basis, depending on your volume of sales. Contact the Taxpayer
Assistance Division, 877/252-3052 or www.dornc.com.
•
When needed, update your principal office address and registered agent with the N.C.
Secretary of State. For a Change of Registered Office/Agent form, call the N.C. Department
of the Secretary of State (919/807-2225).
•
Follow all state and federal laws related to employment, including I-9, W-2, and W-4 forms;
withholding taxes; and posting all compliance posters. For free compliance posters, call
800/625-2267 (N.C. Department of Labor), 866/487-2365 (U.S. Department of Labor), and
800/688-8349 (N.C. Industrial Commission).
Crisis Response Procedures
Emergency Evacuation Plan (Animals)
Emergencies may include, but are not limited to, natural disasters such as tornados or floods, gas
leaks, fire, chemical hazards. Staff must be prepared to safely manage each type of
emergency.
ADVANCE PREPAREDNESS
The following documents and equipment should be easily accessible in case of an emergency.
 Transport vehicle
 Employee phone and emergency contact list – laminated and ready for safe travel
(Phone Tree)
59
Sample Operations Manual
Risk Management
AFTER HOURS PREPAREDNESS
 Phone tree activated
 Contact info for families of all animals at clinic
RESPONSE
Responsibilities of Clinic Director and Executive Director in emergency
1. Makes decision to evacuate and leads evacuation
2. Communicates with RVTs and veterinarian to determine status of animal evacuation,
allowing a decision to be made about staff evacuation
3. Monitors the condition of staff and other responders on scene
All animals will be loaded into their carriers or crates and loaded into the [CLINIC NAME] van.
From there staff will evaluate the need. Owners will be contacted to meet the van at the
clinic location or a safe location determined by staff. If alternative housing to the clinic is
needed, animals will be taken to the following locations:
If during business hours (8am-5pm M-F)
Contact Person:
Phone Number:
If after hours:
Contact Person:
Phone Number:
*Animals will be boarded until their owners can be contacted and retrieve the animals.
Responsibilities of Vet Techs and Veterinarians
1. Manage the internal movement of animals to outside the building
2. Manage the external evacuation site (i.e. parking lot) – ensuring that animals vacate the
property to an off-site location
Responsibilities of Office staff
1. Follow orders of Clinic Director
2. If moving animals, listen to RVTs and Veterinarians and do so in a quick and orderly
manner
3. Ensure that materials necessary to provide temporary care get out of evacuation site
and reach temporary staging location including crates/carriers and two week supply of
dog and cat food to feed all animals in our care.
Emergency Numbers
Fire, Medical, City Police 911
Police Department Direct: 828-252-1110
Fire Department Direct: 828-259-5636
Health Department: 828-250-5000
Animal Control: 828-253-1195
Code of Conduct
Reference the HR Manual
60
Sample Operations Manual
Forms
Forms
Visit our website www.humanealliance.org for form examples
61